Emergency Department Care

Acute mitral regurgitation is a specific case in which immediate intervention in the ED can make a difference.

If the etiology is myocardial infarction, infusion of thrombolytics may reestablish the blood flow to the papillary muscle, possibly restoring function.

The mainstay of medical treatment in most other cases of mitral regurgitation is afterload reduction.

Afterload reduction decreases the impedance to left ventricular ejection and, as a result, decreases the regurgitant volume.

The treatment of pulmonary edema should include oxygen, diuretics, nitrates, and early intubation if respiratory failure results.

These individuals can benefit from afterload reduction with nitroprusside, even in the setting of a normal blood pressure.

Do not attempt to alleviate tachycardia with beta-blockers. Mild-to-moderate tachycardia is beneficial in these patients because it allows less time for the heart to have backfill, which lowers regurgitant volume.

Rapid atrial fibrillation secondary to chronic mitral regurgitation should be controlled with digoxin or diltiazem.

The physician should consider cardioversion in refractory or unstable patients. If cardioversion is effective, however, the restored sinus rhythm usually is transient due to the left atrium being severely dilated.

Consultations

In the setting of acute regurgitation secondary to an acute myocardial infarction, a cardiologist should be involved early. Echocardiography is necessary in order to look for papillary muscle rupture. Interventional cardiology for emergency angioplasty, as an alternative to thrombolysis, should be obtained as per protocol in institutions with such capability.

For highly suspicious cases, a cardiothoracic surgeon should be notified as soon as possible, even before echocardiography is performed. This will allow the surgical team to mobilize.